- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $602.56 / $2,187.76
| Professional | | $380.19 | $602.56 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $151.36 / $467.74
| Professional | 26 | $85.11 | $151.36 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $467.74 / $977.24
| Professional | TC | $295.12 | $467.74 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $562.34
| Professional | | $131.83 | $131.83 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $162.18
| Facility | 26 | $131.83 | $131.83 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $851.14 / $1,258.93
| Professional | | $562.34 | $851.14 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $131.83 / $239.88
| Professional | 26 | $60.26 | $131.83 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $660.69 / $1,122.02
| Professional | TC | $281.84 | $660.69 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $660.69 / $1,202.26
| Professional | | $602.56 | $660.69 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $162.18
| Facility | 26 | $131.83 | $131.83 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $891.25 / $1,000.00
| Professional | | $562.34 | $891.25 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $131.83 / $194.98
| Professional | 26 | $87.10 | $131.83 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $512.86 / $831.76
| Professional | TC | $288.40 | $512.86 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $630.96 / $1,174.90
| Professional | | $338.84 | $630.96 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $79.43 / $199.53
| Professional | 26 | $77.62 | $79.43 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $489.78 / $933.25
| Professional | TC | $257.04 | $489.78 | $933.25 |